Journal of Gerontology: SOCIAL SCIENCES
1998, Vol. 53B, No. 5, S267-S277
Copyright 1998 by The Gemntological Society of America
Stress Reduction for Family Caregivers:
Effects of Adult Day Care Use
Steven H. Zarit,1 Mary Ann Parris Stephens,2 Aloen Townsend,2 and Rickey Greene3
'Gerontology Center, The Pennsylvania State University.
department of Psychology, Kent State University, Kent, Ohio.
3
New Jersey State Department of Health and Senior Services, Trenton, New Jersey.
Objectives. This study reports the findings of an evaluation of the psychological benefits of use of adult day care by
family caregivers assisting a relative with dementia.
Methods. The study used a quasi-experimental design in which caregivers in the treatment group used substantial
amounts of services, whereas caregivers in a control group did not use day care at any point during the evaluation and
only small amounts of other respite services. The evaluation was guided by the stress process model of caregiving
which distinguishes between appraisals of primary stressors and well-being.
Results. Results after 3 months of day care use showed that the treatment group had significantly lower scores than
the control group on two of the three measures of primary appraisals (overload and strain) and two of the three measures of well-being (depression and anger). Findings at one year showed that the treatment group had significantly
lower scores on overload and depression than the control group.
Discussion. These results demonstrate that use of adult day care by caregivers of dementia patients results in lower
levels of caregiving-related stress and better psychological well-being when compared to that of controls.
C
ARING for a disabled older person is one of the most
stressful and challenging events for families over the
life course. Particularly when caring for a relative suffering
from dementia, families are faced with often overwhelming
and uncontrollable stress that can take a toll on their emotional health and well-being (Aneshensel, Pearlin, Mullan,
Zarit, & Whitlatch, 1995; Schulz, O'Brien, Bookwala, &
Fleissner, 1995; Vitaliano, Russo, Young, Teri, & Maiuro,
1991; Wright, Clipp, & George, 1993). There is a growing
recognition of the need to develop programs designed to
relieve caregiver stress and to alleviate the negative effects
of caregiving on their emotional health.
One potentially promising approach to helping family
caregivers is adult day care. Adult day care programs provide out-of-home services such as socializing, medical
care, and therapeutic activities for older adults with a variety of impairments, including dementia (Weissert et al.,
1990). Adult day care programs are offered in a variety of
settings, both freestanding and institutional. Day care services give caregivers regular time away from their care responsibilities so they can devote attention to other areas of
their lives and can restore the psychological and social resources necessary for their own well-being. The purpose of
this study was to evaluate the effectiveness of adult day
care services in alleviating caregiving stress and improving
psychological well-being for primary caregivers to relatives with dementia.
Review of the Literature
There have been relatively few prior systematic evaluations of the benefits of using adult day care programs for
family caregivers' stress and well-being. Some of the available studies focus only on the effects of using adult day
care, whereas others mix together people using adult day
care services or other types of respite (e.g., in-home respite). Only four studies (Gottlieb & Johnson, 1995; Guttman, 1991; Henry & Capitman, 1995; Strain, Chappell, &
Blandford, 1988) have focused exclusively on the effects of
adult day care services on family caregivers' stress and
well-being, and their results do not consistently show positive effects.
Gottlieb and Johnson (1995) reported that use of adult
day care during a 5-month period was associated with decreases in perceived stress, anxiety, and somatic complaints, but not depressive symptoms. Guttman (1991)
found similar significant effects on caregiver stress but not
on depression over a 6-month period of day care use. Strain
and colleagues (1988) found that caregivers' life satisfaction increased over a 1-year period of using adult day care
services. In contrast, using data from a national demonstration, Henry and Capitman (1995) reported no effects of
day care use on caregivers' stress but did not assess caregivers' psychological well-being.
Studies have also focused on the effects of using any
type of respite, where adult day care was one option. Lawton, Brody, and Saperstein (1989) assigned caregivers of
relatives with dementia to a treatment group that received
case management to link them to respite services (including adult day care and in-home respite) or a control group
that received only lists of services available in their community. The results after 1 year indicated no significant differences between the treatment and control groups with reS267
S268
ZARITETAL
spect to psychological well-being or caregiving stress. The
only exception was that the treatment group indicated
slightly more subjective relief than the control group.
Montgomery and Borgatta (1989) assigned caregivers to
five groups receiving different combinations of services (including two groups who could have used adult day care) or
to a no-service control group. Over a 12-month period, they
found that subjective burden declined for all treatment
groups, but no such decline was evident in the control condition. In a subsequent study, Kosloski and Montgomery
(1993) compared the effects of using either adult day care
or in-home respite (vs being in a wait-list control group) on
the stress and well-being of dementia caregivers. Over a 6month period, caregivers in the treatment group reported
increases in morale and decreases in subjective burden.
Cox (1997) examined changes in depressive symptoms
and caregiving burden over a 6-month period among family
caregivers to relatives with dementia who were already enrolled in day care and other respite programs. No control
group was available for longitudinal comparisons. Significant decreases were reported in caregiving burden, but not
in depressive symptomatology or anxiety.
Reviews of prior research on respite care suggest that
problems in design and measurement may have hindered
the ability of these studies to demonstrate consistently positive effects (Knight, Lutzky, & Macofsky-Urban, 1993;
Montgomery & Kosloski, 1995; Zarit, 1990). One serious
problem in some of these studies is that the intervention
was not implemented in sufficient amounts, so that treatment groups received little or even no service at all. As an
example, Lawton et al. (1989) reported that service use in
the treatment group averaged 10 days of day care or 63
hours of in-home respite over a year. Similar findings are
reported by Montgomery and Borgatta (1989), where one
third of caregivers who were assigned to treatment groups
(eligible to receive respite at no cost) used no services at all.
A related problem in prior studies is the inadequate use of
control groups. On the one hand, only one of the studies that
specifically evaluated day care included a control group
(Guttman, 1991), but did not use the control group in longitudinal analyses. Therefore, these studies were not able to assess
changes in caregiving stress and well-being that could have
occurred without the treatment. On the other hand, many of
the studies that evaluated day care and other services combined had control groups, but they did not exclude from analyses caregivers in the control group who used services similar
to those used by the treatment group. In the Lawton et al.
study (1989), for example, some caregivers in the control
group utilized amounts of respite services similar to those of
the treatment group. The resulting comparison between a
treatment group receiving a relatively small amount of respite
and a control group receiving some amount of similar services
would not be expected to produce large differences in stress
and well-being. Although some have concluded from such
findings that respite does not help families (e.g., Callahan,
1989), another possibility is that the results may be due to inadequate implementation of the intervention and the breakdown of the distinction between treatment and control groups.
A further problem in previous research is that some studies did not assess caregiving stress and caregivers' well-
being before the use of respite services. For example, in research reported by Henry and Capitman (1995), Strain and
colleagues (1988), and Guttman (1991), caregivers were already using services at the time the studies began. Without
pretreatment measures, these studies have no baseline for
detecting the amount of change taking place in caregivers'
stress and well-being due to the treatment. Moreover, some
studies did not control for the amount of services used by
caregivers prior to the studies' initial assessments (Gottlieb
& Johnson, 1995; Kosloski & Montgomery, 1993; Montgomery & Borgatta, 1989). Thus, it is possible that the effects of service use had already begun to occur before the
initial assessment of caregivers' stress and well-being.
Another limitation of prior studies is that none investigated the effects of service use on caregivers' stress and wellbeing in both short-term and long-term periods. Thus, it is
not possible to determine whether the same pattern of change
would be found over various periods of time. The duration of
the intervention and the intervals between assessments have
varied across prior studies. Intervals ranged from as short a
period as 5 or 6 months (Cox, 1997; Gottlieb & Johnson,
1995; Guttman, 1991; Henry & Capitman, 1995; Kosloski &
Montgomery, 1993) to as long as 12 months (Lawton et al.,
1989; Montgomery & Borgatta, 1989; Strain et al., 1988).
A final limitation in prior studies is the lack of specificity in
selecting outcomes sensitive enough to detect intervention effects. There is ample evidence that caregiving stress and wellbeing can best be described using a multidimensional approach (e.g., Aneshensel et al., 1995), and that interventions
are likely to address some dimensions of stress and wellbeing more than others. Several prior studies evaluating adult
day care use included only caregiving stress measures as outcomes (Henry & Capitman, 1995; Montgomery & Borgatta,
1989), one included only psychological well-being (Strain et
al., 1988), and others included both (Cox, 1997; Gottlieb &
Johnson, 1995; Guttman, 1991; Kosloski & Montgomery,
1993; Lawton et al., 1989). Thus, some studies may have
omitted domains where effects might be expected to occur,
whereas others have included multiple domains but have not
specified which domain might be more strongly affected.
The Present Study
The present study is an evaluation of the psychological
benefits of adult day care for family caregivers of relatives
with dementia. The study was designed to address six limitations in prior research:
1. The treatment group in the present investigation used
substantial amounts of day care. Our evaluation included only those caregivers whose relative used day
care at least 2 days per week during the assessment interval. This level of participation was selected based on
reports from the day care programs that 2 days a week
represented a minimum amount of service use for families to experience psychological benefits.
2. The control group did not use adult day care services at
all (and only minimal amounts of other formal services)
during the course of the evaluation.
3. Our study obtained pretreatment measures of stress and
well-being for both the treatment and control groups.
STRESS REDUCTION FOR FAMILY CAREGIVERS
This enables us to compare change not only within the
treatment group, but also between the treatment and
control groups.
4. Restrictions were placed on the types and amounts of
services caregivers in the present study could have used
prior to initial assessment. By controlling for prior service use, we are better able to assess changes specifically associated with day care use.
5. The present study examined the effects of adult day care
use in both the short term (i.e., 3 months) and in the long
term (i.e., 12 months).
6. Measurement was guided by a theoretical model that
specified changes most likely to occur as a result of
using day care. We drew upon Pearlin's stress-process
model (Pearlin, Mullan, Semple, & Skaff, 1990; Aneshensel et al., 1995), which distinguishes between appraisals of primary caregiving stressors and general psychological well-being. The present study operationalized
appraisals of primary stressors as feelings of role captivity, overload, and worry and strain. Measures of depressive symptomatology, anger, and positive affect were
used to represent psychological well-being.
Using the stress-process model, our evaluation of adult
day care predicted differential effects of day care use on
stress appraisals and well-being. Every day, caregivers are
faced with a variety of challenges and demands that they
appraise in various ways. An intervention designed to provide time away from caregiving responsibilities would be
expected to affect caregivers' appraisals of primary stressors. In contrast to these appraisals, which stem directly
from the provision of care, psychological well-being is determined by events in caregiving as well as those occurring
in other life domains. Thus, we hypothesized that using
adult day care services would have a stronger effect on appraisals of primary stressors than on well-being. Specifically, using adult day care was expected to substantially
decrease caregivers' negative appraisals of caregiving stressors and, to a lesser degree, to increase their psychological
well-being, both in the short term and in the long term.
We conceptualized the main benefits of adult day care for
caregivers as time away from their relative on a regular,
sustained basis. All day care programs participating in this
study made it possible for caregivers to have predictable,
substantial amounts of time away from caregiving. Nearly
all the participating centers were open 5 days a week for an
average of 7 hours per day. Many centers had extended
hours to accommodate working caregivers, and a few had
weekend hours. Additionally, transportation was available
in all programs to bring dementia clients from their homes
to the day care sites. Thus, each center participating in the
research provided sufficient opportunity for caregivers to be
relieved from their caregiving responsibilities.
METHOD
Design and Procedures
A quasi-experimental design was used to compare two
groups of primary family caregivers. The treatment group
comprised caregivers who enrolled their relatives in adult
day care services in New Jersey, and the control group was
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composed of caregivers from another state whose relatives
were not enrolled in such services. Neither group was
aware of the existence of the other group.
New Jersey was chosen as the treatment site because it
has a statewide network of adult day care programs that provide services for people with Alzheimer's disease or other
dementing illnesses. An additional feature is a statewide
subsidy for the cost of services, which is provided through
the Department of Health and Senior Services for caregivers
of a relative with dementia with low and moderate income.
This removes a major obstacle to service use and makes day
care affordable to all families regardless of income.
Recruitment of a control sample of nonusers of day care
in New Jersey would be biased in that it would include people who self-selected not to participate in a readily accessible program. Random assignment also was not possible because the subsidy is an entitlement and because of the long
period (one year) that caregivers in the control group would
be asked to refrain from using services. Thus, the control
group was selected from northeastern Ohio and two counties in Pennsylvania bordering Ohio. This region was selected for two reasons. First, as indicated by census data,
characteristics of the population in New Jersey and northeastern Ohio region are similar on relevant indicators (e.g.,
per capita income, median education, proportion of the
population 65 or over, unemployment rates, population
density, proportion of minorities). Second, day care programs and subsidies in the northeastern Ohio region are
very limited.
Interviews took approximately 75 minutes and were conducted in caregivers' homes or another location of their
choice. Both groups were assessed at three intervals over
one year: the baseline interview (Tl), 3 months later (T2),
and 12 months (T3) following the baseline interview. The
Tl interview in New Jersey took place just prior to the care
recipient beginning to use day care or within the first five
days of service use. The selection of 3 months for the first
follow-up interview was based on pilot data, which suggested this was a sufficient period for benefits to families to
be noticeable. Pilot data also suggested that attrition from
day care is highest in the first 3 months as some families
use the service only briefly. The 12-month period for assessing long-term effects was selected in order to be comparable to other respite studies.
Recruitment.—We invited all day care centers from 16 of
New Jersey's 21 counties to participate in the study. Five primarily rural counties were excluded so that the areas from
which caregivers were recruited in New Jersey would be
comparable in terms of population density to the recruitment
area for control subjects. Of the 80 day care programs contacted, 45 (56%) agreed to participate. The primary reason
programs gave for not participating in the study was that they
did not offer specialized services for clients with dementia.
When family members made the decision to enroll their
relative in one of the 45 day care programs, the day care
staff briefly informed them of the study and asked if they
would be willing to participate. Day care staff referred willing family members to project staff. The treatment group
included people receiving a state subsidy and those who
S270
ZARITETAL.
had incomes above the eligibility level for a subsidy. In the
control group, caregivers were recruited through newspaper
solicitations, brochures, and newsletters distributed by
Alzheimer's Association chapters. Every effort was made
to interview any potential eligible caregiver.
Eligibility criteria.—Criteria for eligibility at Tl in both
the treatment and control groups were that: (a) the relative
had a diagnosis of dementia; (b) the caregiver was the person
who spent the most time assisting the relative; (c) the caregiver was not currently using day care services for the relative and had not used these services in the prior 3 months; (d)
the caregiver was not currently using more than 8 hours of
any other type of paid help per week for their relative; and
(e) the relative had to be independently mobile or mobile
with assistive devices. The latter was a requirement for admission to the day care programs in New Jersey, and so was
applied to the sample in Ohio to increase comparability.
A maximum of 8 hours per week of formal service use
was chosen for two reasons. First, for day care users, it was
important to ensure that there would be a substantial change
in the amount of help received when the relative began attending day care and that day care would not simply substitute for other kinds of formal services. Second, it was important to ensure that the control group not only was uninvolved
in day care services but that they were not using high levels
of similar kinds of services. It seemed unrealistic to require
that caregivers in the control group receive no formal help at
all, so a threshold of 8 hours was selected based on recommendations of day care program staff regarding how much
formal help is needed to make a difference for caregivers'
well-being. Prior research has also reported little effect of
small amounts of respite (Lundervold & Lewin, 1987).
One other eligibility requirement was made for the control group. In addition to not currently using day care, caregivers had to indicate that they would be willing to use
such services if they were available and affordable. This requirement ensured that the control group would not have
self-selected out of these services under any conditions.
A total of 445 individuals was screened for eligibility in the
treatment group, and 261 (59%) were eligible and interviewed at Tl. The three most frequent reasons for ineligibility
at baseline were that the caregiver was receiving more than 8
hours of paid help per week (29% of ineligible caregivers),
the relative had used more than 5 days of day care prior to the
Tl interview (22%), or the relative never began using day
care (16%). A total of 608 individuals were screened for eligibility in the control group, and 305 (50%) were eligible and
interviewed at Tl. The three most frequent reasons for ineligibility in the control group were that the caregiver was receiving more than 8 hours of paid help per week (31% of ineligible caregivers), the relative was using day care (21%), or the
caregiver was not the primary caregiver (14%).
For those interviewed at Tl, several criteria were required for inclusion in the present longitudinal analyses.
First, caregivers had to have complete data for the given
analysis (i.e., either Tl and T2 or Tl and T3). In both
groups, caregivers had to continue to be the primary caregiver to their community-residing relative. To ensure adequate exposure to the intervention, the treatment group had
to use the service at least two times per week for a period
of 3 months prior to T2 and for 12 months prior to T3.
Caregivers in the control group were excluded from analyses if they began to use day care services, used more than 8
hours per week of other paid help, or if their relatives'
health declined to the point where they could not have participated in a day care program. These criteria were imposed to provide a clear contrast between a treatment group
that received an adequate amount of adult day care services
and a control group that received no adult day care (and
only minimal levels of other kinds of formal services).
Subjects
For the T1-T2 (hereafter referred to as the short-term)
panel analyses, data were available from 121 caregivers in
the treatment group (46% of those interviewed at Tl) and
203 caregivers in the control group (67% of those interviewed at Tl). For the treatment group, the three most frequent reasons for exclusion from the short-term panel analyses were that the relative had stopped using day care services
by T2 (30%), the relative had been institutionalized (21%),
or the relative had used day care services for less than the
minimum amount required for the study (10%). For the control group, the three most frequent reasons for exclusion
were that the relative had been institutionalized (27%), caregivers were using more than 8 hours per week of formal services (22%), or the relative had begun using day care services (20%). The number of refusals at T2 was small for both
groups (1 % of the treatment group, 4% of the control group).
For the T1-T3 (hereafter referred to as the long-term)
panel analyses, data were available from 73 caregivers in
the treatment group (28% of those interviewed at Tl) and
120 caregivers in the control group (39% of those interviewed at Tl). For the treatment group, the three most frequent reasons for exclusion were that the relative had been
institutionalized (44%), the relative had stopped using day
care services by T3 (22%), or the relative had died (8%).
For the control group, the three most frequent reasons for
exclusion were that the relative had been institutionalized
(26%), the relative had begun using day care services
(21%), or caregivers were using more than 8 hours per
week of formal services (19%). At T3, the number of refusals was again small (4% for the treatment group, 1% for
the controls). Included in the long-term panel were 22 people (15 in the treatment group, 7 among controls) who were
not part of the short-term panel but who met all criteria for
inclusion at T3. It had not been possible to interview these
caregivers at T2 in a timely way (within 3.5 weeks of the
scheduled time), but we were able to ascertain that they met
all criteria for continued inclusion in the sample at that time
(for the treatment group, use of at least 2 days of day care a
week; for controls, not enrolled in day care).
Demographic characteristics of the short-term and longterm panels are shown in Table 1. For the short-term panel
as a whole (N = 324), caregivers were primarily women
(80.6%), White (89.8%), and had an average age of 60.1
years (SD = 13.7, range = 23-84). In terms of their relationships to the relatives, 43.8% were spouses, 42.3% were
adult children, and 13.9% were other relatives including inlaws, siblings, grandchildren, and nieces and nephews. The
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STRESS REDUCTION FOR FAMILY CAREGIVERS
Table 1. Demographic Characteristics of Caregivers and Relatives atTl
Long-Term Panel
Short-Term Panel
Participant
Age
Gender (female)
Race (Caucasian)
Relationship
Spouse
Adult child
Other
Education (years)
Family income"
Relative
Age
Gender (female)
Treatment
(n =121)
Control
(n = 203)
Totals
Treatment
(n = 73)
Control
(n=120)
Totals
M
(SD)
%
%
59.4
(14.6)
80.2
87.6
60.5
(13.2)
80.8
91.1
60.1
(13.7)
80.6
89.8
56.2*
(13.8)
75.3
83.6
61.0*
(12.5)
78.3
91.7
59.2
(13.2)
77.2
88.6
%
%
%
M
(SD)
M
(SD)
41.3
45.5
13.2
13.3
(2.3)
6.1*
(2.4)
45.3
40.4
14.3
13.3
(2.1)
5.5*
(2.2)
43.8
42.3
13.9
13.3
(2.2)
5.7
(2.3)
31.5*
54.8
13.7
13.3
(2.3)
6.3*
(2.6)
49.2*
38.3
12.5
13.4
(2.0)
5.5*
(2.3)
42.5
44.6
13.0
13.4
(2.1)
5.8
(2.4)
M
(SD)
%
78.2
(8.0)
61.2
77.3
(8.5)
60.1
77.6
(8.3)
60.5
77.5
(8.5)
72.6
76.2
(8.4)
59.2
76.7
(8-4)
64.2
•1 = < $5,000; 2 = $5,000-$9,999; 3 = $10,000-$ 14,999; 4 = $15,000-$19,999; 5 = $20,000-$24,999; 6 = $25,000-$29,999; 7 = $30,000-$39,999; 8 =
$40,000-$59,999; 9 = $60,000-$79,999; 10 = $80,000 or over.
•Significant difference between treatment and control groups atp < .05 in the short-term or long-term panel.
mean education level for all caregivers was 13.3 years (SD
= 2.2, range = 5-17). The average age of their relatives was
77.6 years (SD = 8.3, range = 45-96). A majority of the relatives were women (60.5%). The most recent diagnosis of the
relatives was primarily Alzheimer's disease (60.8%), and
the remainder involved other forms of dementia (e.g., multiinfarct dementia).
Table 2 summarizes relatives' impairments and caregivers'
involvement. For the short-term panel, the average number of
personal activities of daily living (PADL; eating, dressing/undressing, grooming, bathing, toileting) with which the relatives needed help was 2.5 (SD = 1.7, range = 0-5). The relatives required assistance with an average of 4.7 instrumental
activities of daily living (IADL; housework, grocery shopping, cooking, laundry, transportation; SD = 0.8, range = 0-5).
Of six possible memory problems, relatives were reported to
exhibit an average of 5.3 (SD = 0.9, range = 1-6), and of 14
problematic behaviors (e.g., anger or aggression), relatives
were reported to exhibit an average of 6.6 (SD = 2.8, range =
0-13). Caregivers had been caring for their relatives for an average of 3.2 years (SD = 2.8, range = 3 months-17 years).
In terms of the caregivers' involvement in caregiving,
they spent an average of 2.1 hours on a typical day assisting
the relatives with personal care activities (SD = 2.8, range =
0-24) and 4.9 hours assisting with instrumental activities
(SD = 3.9, range = 0-24). On average, caregivers spent 5.5
hours (SD = 5.0, range = 0-24) and 5.5 hours (SD = 5.3,
range = 0-24) on a typical day dealing with the relatives'
memory and behavior problems, respectively. On average,
caregivers reported spending "most of the time" (M - 3.3)
supervising their relatives (SD = 0.7, range = 2-4), on a 4point scale from "never" to "all of the time."
In order to determine whether caregivers in the short-term
panel who did not continue in the long-term panel (n = 153)
differed from those who did (n = 193), comparisons were
made between these two groups on demographic characteristics of caregivers and relatives, the severity of the relatives' impairment, and the caregivers' involvement. (As
noted earlier, the long-term panel includes 22 people who
were not part of the short-term panel). Those caregivers who
were in the long-term panel were more likely to be male (x2
= 4.6, p < .05) and to be caring for a younger relative
[F( 1,344) = 4.95, p < .05] than were caregivers excluded
from this group. Caregivers in the long-term group also reported that their relatives had fewer behavior problems
[F(l,344) = 7.6, p < .01]. We also compared the short-term
and long-term panels from the treatment group on adult day
care use. There was no significant difference in the number
of adult day care sessions their relatives attended per week
between the short-term and long-term groups [M = 2.93 and
3.26 times per week, F (1,119) = 2.38, p >.10]. There was
also no evidence that duration of use was related to the specific adult day care program caregivers used. Short-term and
long-term use was distributed equally across the participating adult day care programs.
Measures
Twenty-three items were included to assess appraisals of
primary stressors. Items asked caregivers to report how
often each statement was true in the past month on a 4point scale ranging from "never" to "all of the time." Eight
items were taken from Pearlin et al. (1990), and 15 items
were created for the present study. A principal components
analysis was used to examine the underlying structure of
the combined pool of 23 items. Four factors were extracted
from this analysis, and three were selected to serve as
scales for the present study. A copy of the measures is
available from the authors. The means, standard deviations,
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ZARITETAL
Table 2. Number of Relatives' Impairments and Hours of Caregivers' Involvement in Caregiving at Tl,
Means and Standard Deviations (SD)
Short-Term Panel
Relatives' Impairments
PADL
IADL
Memory problems
Behavior problems
Years caregiving
Time Involvement in Caregiving
PADL'
IADL1
Memory problems"
Behavior problems'
Supervision"
Treatment
(«= 121)
Control
(n = 203)
2.9*
(1.6)
4.8
(0.7)
5.4
(0.8)
7.1*
(2.8)
2.2*
(1.7)
4.6
(0.8)
5.3
(0.9)
6.3*
(2.8)
Long-Term Panel
Totals
Treatment
(n = 73)
Control
(n = 120)
Totals
2.5
(1.6)
4.7
(0.9)
5.3
(1.0)
6.8*
(2.8)
2.7*
(2.8)
2.2
(1.7)
4.6
(0.8)
5.3
(0.9)
5.8*
(2.8)
3.7*
(3.0)
2.3
(1.7)
4.7
(0.8)
5.3
(0.9)
6.2
(2.8)
3.3
(3.0)
2.5*
(2.8)
5.6*
(4.3)
6.4*
(5.7)
5.7
(5.4)
3.2
(0.7)
1.6*
(2.1)
4.4*
(3.8)
4.8*
(4.8)
4.4
(4.6)
3.4
(0.7)
1.9
(2.4)
4.8
(4.0)
5.4
(5.2)
4.9
(4.9)
3.3
(0.7)
2.9
3.4
(2.8)
(2.7)
2.5
(1.7)
4.7
(0.8)
5.3
(0.9)
6.6
(2.8)
3.2
(2.8)
3.0*
(3.7)
6.0*
(4.5)
6.7*
(5.3)
7.2*
(5.8)
3.3
(0.7)
1.6*
(2.0)
4.2*
(3.4)
4.7*
(4.6)
4.5*
(4.8)
3.3
(0.7)
2.1
(2.8)
4.9
(3.9)
5.5
(5.0)
5.5
(5.3)
3.3
(0.7)
•Hours per day that caregivers assist with this problem.
Coded 1 = Never; 2 = Some of the time; 3 = Most of the time; 4 = All of the time.
•Significant difference between treatment and control groups at p < .05 in the short-term or long-term panel.
b
and alpha coefficients for these scales over time are shown
in Table 3.
Role captivity.—This scale consists of three items developed by Pearlin and associates (1990). It measures the extent to which caregivers feel trapped and constrained in the
caregiving role (e.g., "I wish I were free to lead a life of my
own"). The potential range for scores was 3-12, with
higher scores indicating more role captivity.
Overload.—This seven-item scale assesses the extent to
which the demands of caregiving are exhausting caregivers'
time and energy (e.g., "I have more things to do than I can
handle"). It includes four items developed by Pearlin and associates (1990) and three new items (e.g., "I can count on a
block of time to use as I like"). The potential range for scores
was 7-28, with higher scores indicating more overload.
Worry and strain.—The eight items on this scale were
developed for this study to assess the extent to which caregiving is a source of chronic physical and psychological
strain (e.g., "I feel more and more tense as the day goes
on," "I don't know what to expect from one hour to the
next"). The potential range for scores was 8-32. Higher
scores indicate more worry and strain.
Depression.—The 20-item Center for Epidemiological
Studies Depression Scale (CES-D; Radloff, 1977) was used
to assess symptoms of emotional distress and depression in
caregivers. This scale has been widely used with a variety of
populations, including caregivers (Lawton et al., 1989).
Caregivers report how often they experienced each symptom in the past week on a 4-point scale ranging from "rarely
or none of the time" to "most or all of the time." The potential range for scores is 0-60, with higher scores representing
greater depressive symptomatology. The means, standard
deviations, and alpha coefficients for this and the other two
well-being scales over time are shown in Table 3.
Anger.—This four-item scale consists of three items
adapted from the Brief Symptom Inventory (Derogatis &
Spencer, 1982) and one item adapted from the anger scale
used by Pearlin and associates (1990). This scale measures feelings of anger and irritation (e.g., "I had temper
outbursts I couldn't control"). Caregivers report how often
each statement was true in the past week on a 4-point
scale ranging from "not at all" to "very much." Potential
scores could range from 4-16, with higher scores indicating greater anger.
Positive affect.—This 10-item subscale of the Positive
and Negative Affect Schedule (PANAS; Watson, Clark, &
Tellegen, 1988) measures positive feelings. Caregivers report the extent to which they have experienced the particular affective state in the past week by rating each descriptor
on a 5-point scale, ranging from "not at all" to "extremely."
Potential scores could range from 10-50, with higher
scores representing more positive affect.
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STRESS REDUCTION FOR FAMILY CAREGIVERS
Tables 4 and 5 present the correlations among the three
measures of appraisals of primary stressors and the three
measures of well-being for the sample as a whole (i.e.,
combining treatment and control groups) for the short-term
and long-term panels, respectively.
Analysis Plan
In order to determine whether the treatment and control
groups were equivalent at baseline on the dependent vari-
ables (i.e., the three stress appraisal measures and the three
well-being measures), one-way analyses of variance
(ANOVAs) were used. These analyses were conducted twice:
once for the short-term panel and again for the long-term
panel. Because the study's purpose was to assess change over
time in appraisals and well-being, ANCOVA (analysis of covariance) was used to test for change in the short-term panel
over three months and in the long-term panel over a year. Tl
status on a given dependent variable was used as a covariate
Table 3. Descriptive Information on Stress Appraisals and Weil-Being for the Short- and Long-Term Panels
Long-Term Panel
Short-Term Panel
Control
(n = 203)
Treatment
(n=121)
Treatment
(n = 73)
Tl
T2
Tl
Role captivity
M
SD
Alpha
6.9
(2.6)
.82
6.6
(2.5)
.81
6.4
(2.6)
.82
6.6
(2.6)
.81
Overload
M
SD
Alpha
22.2*
(3.3)
.71
20.8
(3.3)
.74
20.6*
(3.4)
.72
Worry and strain
M
SD
Alpha
20.1*
(4.5)
.81
18.6
(4.4)
.78
18.3*
(12.4)
.92
Anger
M
SD
Alpha
Positive affect
M
SD
Alpha
Depression
M
SD
Alpha
Tl
Control
(n =120)
T3
Tl
T3
6.3
(2.4)
.79
6.2
(2.2)
.73
5.9
(2.6)
.84
6.1
(2.5)
.82
20.8
(3.4)
.73
21.7*
(3.4)
.74
20.2
(3.4)
.77
20.5*
(3.5)
.70
20.8
(3.3)
.66
18.5*
(4.3)
18.3
(4.5)
.76
.79
19.2*
(4.3)
.81
17.9
(4.3)
.82
17.9*
(4.2)
.75
17.7
(4.7)
.82
15.8
(11.5)
.92
14.9*
(10.2)
.89
15.4
(11.0)
.91
16.4
(12.1)
.92
14.0
(11.1)
.92
13.7
(10.4)
.90
14.8
(12.2)
.93
8.2*
(2.9)
.78
7.7
(2.7)
.78
7.2*
(2.7)
.75
7.7
(3.0)
.80
7.7
(2.8)
.78
7.5
(2.6)
.75
7.0
(2.8)
.78
7.4
(3.0)
.82
31.7
(7.2)
.87
32.0
(6.2)
.84
32.5
(6.8)
.86
31.6
(7.4)
.89
33.2
(7.5)
.89
32.7
(7.7)
.92
33.9
(7.0)
.87
34.1
(7.6)
.91
T2
*Significant difference at Tl between treatment and control groups at/? < .05 in the short-term or long-term panel.
Table 4. Correlations of Appraisals of Primary Stressors and Well-Being for the Short-Term Panel
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Captivity Tl
Overload Tl
Worry and strain Tl
Depression Tl
Anger Tl
Positive affect Tl
Captivity T2
Overload T2
Worry and strain T2
Depression T2
Anger T2
Positive affect T2
1
2
3
4
5
6
7
8
9
10
11
.38
.61
.49
.43
-.25
.74
.34
.48
.43
.35
-.23
.61
.50
.34
-.23
.39
.69
.45
.40
.26
-.20
.64
.42
-.25
.47
.52
.68
.56
.35
-.25
.59
-.53
.39
.44
.53
.69
.43
-.41
-.29
.34
.26
.32
.46
.58
-.24
-.18
-.19
-.20
-.36
-.19
.59
.42
.60
.50
.41
-.28
.60
.51
.36
-.34
.65
.44
-.38
.62
-.58
-.33
Note: Correlations equal to or greater than . 11 are significant at p < .05. N = 324.
S274
ZARITETAL
Table 5. Correlations of Appraisals of Primary Stressors and Well-Being for the Long-Term Panel
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Captivity Tl
Overload Tl
Worry and strain Tl
Depression Tl
Anger Tl
Positive affect Tl
Captivity T3
Overload T3
Worry and strain T3
Depression T3
Anger T3
Positive affect T3
1
2
3
.35
.59
.47
.40
-.25
.69
.28
.34
.38
.39
-.22
.66
.52
.31
-.25
.39
.63
.48
.44
.27
-.18
.66
.37
-.26
.53
.51
.67
.57
.40
-.20
4
.54
-.53
.40
.40
.49
.67
.47
-.45
5
6
7
8
9
10
11
-.27
.31
.26
.24
.28
.58
-.17
-.13
-.24
-.15
-.29
-.18
.64
.45
.60
.51
.47
-.20
.62
.54
.40
-.33
.71
.51
-.32
.65
-.54
-.36
Note: Correlations equal to or greater than . 14 are significant at p < .05. N = 193.
in the analysis of its effects at T2 or T3 (even for those measures where there was no initial difference between groups).
To determine the need for covariates in addition to Tl
status on the dependent variables, a two-step procedure was
used. First, ANOVAs or a chi-square statistic were used to
determine whether the treatment and control groups were
equivalent at baseline on potential covariates. Potential covariates included demographic characteristics of the participant and relative, the severity of the relative's impairment,
and the participant's involvement in caregiving at Tl. Second, partial correlations were used to determine the relationship between the T2 or T3 dependent variables and any
potential covariate on which the groups differed significantly. We examined whether each of these potential covariates had a partial correlation of .20 or greater with the
T2 or T3 dependent variables, after controlling for the Tl
status on that dependent variable. Any variable that met or
exceeded this criterion was then included as a covariate in
the ANCOVAs along with the Tl status of the relevant dependent variable.
RESULTS
Baseline Comparisons Between Groups
Results of the ANOVAs comparing the treatment and
control groups in the short- and long-term panels on Tl levels of the appraisals of primary stressors and well-being
measures are shown in Table 3. Caregivers in the treatment
group reported on average greater feelings of overload and
worry/strain and more negative affect at Tl in both the
short-term and long-term panels than caregivers in the control group.
To assess the need for covariates other than Tl status on
the dependent variable, ANOVA or a chi-square statistic was
performed on demographic characteristics, severity of impairment, and caregivers' involvement in caregiving at Tl.
The results for the demographic characteristics for the shortand long-term panels are shown in Table 1. In the short-term
panel, the treatment and control groups in this panel differed
significantly on only one of the demographic characteristics
of either caregivers or their relatives, with caregivers in the
treatment group having higher family income. In the longterm panel, significant differences were found for three char-
acteristics. Caregivers in the treatment group were younger
and had higher incomes, on average, than caregivers in the
control group. In addition, caregivers in the treatment group
were more likely to be adult children of the relatives (whereas the control group contained more spouses).
A final set of ANOVAs compared the treatment and control groups on Tl severity of relatives' impairment and caregivers' involvement (i.e., time spent) in various caregiving
activities (Table 2). In the short-term panel, caregivers in the
treatment group were caring for relatives who needed more
assistance in personal care and had more behavior problems;
they spent significantly more hours at Tl assisting with
PADLs and IADLs and dealing with memory and behavior
problems. For the long-term panel, the treatment group had
relatives with more behavior problems at Tl, and spent
more hours assisting the relative with PADLs, IADLs, and
dealing with memory problems.
Partial correlation coefficients were computed between
each of those variables on which the treatment and control
groups differed at Tl and each of the T2 or T3 dependent
variables, controlling for Tl status on that dependent variable. Of the seven variables on which the groups in the
short-term panel differed significantly at Tl (shown in Tables 1 and 2), only one had a partial correlation of .20 or
greater with any of the T2 dependent variables. Specifically, caregivers' income at Tl was related to depression
levels at T2 (r = -.23) after controlling for Tl depression
levels. Of the eight variables on which the groups in the
long-term panel differed significantly at Tl, caregivers' income at Tl was related to depression (r = -.23) and anger
(r = -.21) at T3, and hours spent assisting their relative
with IADLs (r = .20) was related to depression at T3, after
controlling for Tl levels. Based on these results, caregivers' income was included as a covariate along with Tl
depression in the ANCOVAs for T2 depression, and income
and hours assisting the relative with IADLs were used as
covariates in analyses of T3 depression. For analyses involving T3 anger, income was used as a covariate along
withTl anger.
Longitudinal Comparisons Between Groups
Table 6 presents the adjusted means from the longitudinal analyses of stress appraisals and well-being in the short-
STRESS REDUCTION FOR FAMILY CAREGIVERS
S275
Table 6. Adjusted Means From Analyses of Covariance for Stress Appraisals and Weil-Being (Short-Term and Long-Term Panels)
Long-Term Panel (T3)
Short-Term Panel (T2)
Captivity
Overload
Worry and strain
Depression
Anger
Positive affect
Treatment
(n=121)
Control
(n = 203)
6.4
20.2
18.0
14.5
7.3
32.2
6.8
21.3
18.8
16.7
8.0
31.3
F
Treatment
(n = 73)
Control
(n= 120)
F
2.7
15.9**
4.3*
5.1*
5.4*
2.0
6.1
19.8
17.5
12.8
7.3
33.0
6.3
21.2
18.3
16.1
7.6
33.7
0.3
13.4**
2.3
6.1*
0.5
0.6
Note: Means are adjusted forTl status on a given dependent variable. In the short-term panel, depression is adjusted for caregivers' family income. In the
long-term panel, depession is adjusted for caregivers' family income and hours of IADL assistance, and anger is adjusted for caregivers' family income.
*/?<.05; **/?<.01.
term panel. Results of the ANCOVAs indicated that caregivers in the treatment group had significantly lower levels
of overload, worry/strain, depression, and anger at the 3month interval. On all four of these measures, the treatment
group had reported significantly more negative appraisals
and more negative affect at Tl than the control group. By
T2, the direction of these differences had changed such that
the treatment group reported significantly fewer negative
appraisals and less negative affect than the control group.
The adjusted means from the longitudinal analyses of
stress appraisals and well-being in the long-term panel are
also presented in Table 6. Results of the ANCOVAs indicated that the treatment and control groups differed significantly in overload and depression at T3. Specifically, caregivers in the treatment group had lower levels of overload
and depression at the one-year interval.
We considered an alternative hypothesis that differences
in number of behavior problems, which is strongly associated with primary appraisals of stressors and well-being
(Aneshensel et al., 1995), might account for the differences
in outcomes between the treatment and control groups.
Number of behavior problems that occurred in the past
week was significantly higher at Tl in the treatment group
than in the control group for the short-term and long-term
panels. The baseline score for number of behavior problems
was tested as a possible covariate, as described above, but
none of the partial correlations with outcome measures was
.20 or greater. The mean number of behavior problems did
not increase significantly in either the short-term or longterm panels, and the difference in mean number of behavior
problems between the treatment and control groups was stable over time. In the short-term panel, number of reported
behavior problems was 7.1 at Tl and 7.2 at T2 for the treatment group and 6.3 and 6.3 for controls. In the long-term
panel, number of behavior problems was 6.8 at Tl and 6.8
at T3 for the treatment group and 5.8 and 5.7 for controls.
Because the number of behavior problems was stable in
both the treatment and control groups, it is unlikely that behavior problems could have differentially affected the outcomes.
DISCUSSION
The results of this evaluation demonstrate that caregivers
of relatives with dementia who use adult day care experience
lower levels of caregiving-related stress and better psycho-
logical well-being than a control group not using this service. These differences are found in both short-term (3
months) and long-term (12 months) users. As predicted,
using adult day care affected caregivers' appraisals of primary stressors, resulting in lower feelings of overload and
worry/strain, though not reports of role captivity. The findings for global well-being (depression and anger) were
stronger than anticipated, although differences for positive
affect were not significant. Advantages from day care use
were found even though caregivers in the treatment group
were initially more stressed and distressed than those in the
control group. These findings, however, are tempered by the
fact that many caregivers used day care for relatively short
periods of time. Taken together, these results suggest that use
of adult day care for 3 months or more is associated with
lower levels of caregiver stress and distress when compared
to caregivers not using day care or similar respite services.
This study builds upon and extends the few findings of
positive effects in other research on adult day care. Whereas
Gottlieb and Johnson (1995) reported reductions in perceived
stress as a function of day care use, our evaluation found that
day care affects some appraisals of caregiving stress, but not
others. Moreover, although Gottlieb and Johnson, as well as
Guttman (1991) and Strain and associates (1988), showed
that day care can improve some aspects of caregivers' psychological well-being, these studies did not find effects on
depression. Depression is a significant mental health problem
for caregivers of dementia patients (Schulz et al., 1995). Our
study showed that caregivers using adult day care experienced lower anger than controls at 3 months and less depression than controls at 3 months and 1 year. Unlike the evaluations by Gottlieb and Johnson or Strain et al., which did not
include a control group, our evaluation used a carefully selected control group and thus was able to demonstrate that
the reductions in caregiving stress and improvements in
well-being would not have been likely to occur in the absence of the intervention. Also, in contrast to prior work
where the earliest benefits reported were after 5 months of
day care use, we found benefits occurring after 3 months.
Our study highlights the value of a carefully controlled
evaluation, which uses a theory-driven approach to measurement. We included both pretreatment measures and a
control group that did not use day care services for their
relatives at any time during the study. Moreover, our evaluation focused only on those caregivers in the treatment
S276
ZARITETAL.
group who used substantial amounts of day care services
during the assessment intervals. In contrast to prior research on the effects of using respite services (e.g., Kosloski & Montgomery, 1993; Lawton et al., 1989; Montgomery & Borgatta, 1989), the present study makes a clear
contrast between a treatment group that had considerable
exposure to the intervention and a control group that had no
exposure to the intervention during the study. Furthermore,
neither group had exposure to the intervention for at least 3
months prior to the beginning of the study.
Another strength of the present design is that we ensured
that caregivers in both the treatment and control groups had
positive attitudes toward day care use. The treatment group
consisted of caregivers who were seeking adult day care
services, unlike prior studies (e.g., Lawton et al., 1989;
Montgomery & Borgatta, 1989), where services were made
available regardless of caregivers' attitudes. In addition, we
screened caregivers in the control group to ensure that they
would be willing to use the intervention if it were available
and affordable. While a willingness to use a service may not
be the same as readiness to do so, the approach we took reduced the possibility that caregivers in the two groups were
attitudinally dissimilar concerning the use of adult day care
or that those attitudes could explain the results we observed.
In all research using a quasi-experimental design, issues
of pretreatment nonequivalence of treatment and control
groups are paramount (Cook & Campbell, 1979). The concern is that differences that exist prior to the intervention
will threaten the confidence that can be placed in the
study's outcomes. The present study used ANCOVA as one
way to allay this concern. The crossover effects we observed also should reduce this concern. In the short-term
panel, crossover effects were evident in that at baseline
caregivers in the treatment group had significantly more
negative appraisals on two of the three areas we assessed
(overload, worry/strain) and they experienced significantly
more negative affect (depression and anger) than the control group; after their relative had used day care for 3
months, these caregivers experienced significantly less
overload, worry and strain, depression, and anger than the
control group. Thus, the treatment group, which was initially more stressed and distressed than the control group,
became less so after their relatives had used day care services for 3 months.
A crossover effect was also found for one appraisal measure at 1 year, whereby caregivers in the treatment group
experienced significantly higher levels of overload than the
control group at baseline and significantly lower levels of
overload after 1 year of day care use. It is unlikely that alternative explanations such as regression to the mean by either group over time, or naturally occurring fluctuations in
appraisals or well-being, could account for these significant
differences in opposite directions on the pretreatment and
posttreatment measures (Cook & Campbell, 1979). Rather,
these findings indicate that day care results in better psychological functioning for service users than for controls.
The study was guided by theoretical propositions about
the relation of caregiving stressors to outcomes and the likely
effects of day care on the stress process. Measures were selected in domains specific to the caregiving experience (ap-
praisals of primary stressors) and in more global domains of
well-being. We expected that by providing a predictable
block of time away from the relative, day care would be associated with decreases in appraisals of primary stressors,
and this was confirmed for two of the measures (overload
and worry/strain), but not the third (role captivity). Overload
and worry/strain directly reflect the subjective experience of
carrying out tasks and responsibilities, whereas role captivity
deals with feelings that providing care is obligatory (Aneshensel et al., 1995). These feelings of obligation proved more
resistant to change than expected, and may depend on more
enduring features of the caregiving situation than overload
and strain. Day care appears to ease some of the immediate
pressures of caregiving, but not the feeling that caregiving is
an unwanted or unwelcome obligation.
These findings are interesting in light of results from the
Aneshensel et al. (1995) study, which examined both role
captivity and overload over time. In that study, role captivity and overload were equally stable over a 1-year period.
In contrast to the relative stability of these constructs reported by Aneshensel et al., the present study found that
feelings of overload and worry/strain were significantly
lower in the adult day care group than the controls after 3
months. This difference from Aneshensel and colleagues'
results suggests that adult day care use alters subjective
caregiving stress in some, though not all, domains.
Although the use of adult day care had benefits for caregivers' depression and anger, there were no differences in
positive affect. Using a dual model of affect, Lawton and
colleagues (Lawton, Moss, Kleban, Glicksman, & Rovine,
1991) found different antecedents for caregivers' positive
and negative affect. The main determinant of positive affect
was positive caregiving experiences, whereas depression
was determined by subjective burden. Although we did not
investigate positive caregiving experiences, a similar process may have been at work in the present study. Day care
reduced primary appraisals of stressors, which are important antecedents of depression and anger (Aneshensel et al.,
1995), but did not alter the overall course of the relative's
illness and thus could not restore the kinds of positive experiences between caregiver and care recipient that might lead
to more positive affect. Unalleviated feelings of role captivity may also constrain improvements in positive affect.
Another strength of the study is that many of the features of
the intervention could be replicated widely. Adult day care services were provided in existing programs located in a variety
of communities throughout New Jersey. These day care centers had received training in dementia care from the Department of Health and Senior Services and had developed programs that included activities appropriate for dementia
patients. Subsidies were available through the New Jersey Department of Health and Senior Services so that caregivers with
a wide range of social and economic backgrounds could use
day care. These features are not overly costly to implement.
There are some important limitations of this study. The
criteria for inclusion and retention of caregivers were restrictive in order to ensure that a clear contrast could be made between caregivers who used day care and those who did not.
The study focused on caregivers who used adult day care at
least two times per week for 3 months or longer. These re-
STRESS REDUCTION FOR FAMILY CAREGIVERS
strictions, however, may limit generalizability. Another limiting factor is the amount of attrition from the treatment, that
is, the number of caregivers who used adult day care for a
relatively short period of time. Substantial numbers of caregivers were not included in the 3-month or 1-year comparisons because they were no longer using day care at these intervals. A few other caregivers were not included because
they used lesser amounts of day care than required by our
criteria. In contrast to treatment attrition, there was very little
sample attrition, that is, few caregivers refused to be reinterviewed. Nonetheless, it is clear that findings of benefits from
day care must be tempered by the fact that many caregivers
use it for only a brief period of time.
Other limitations are that caregivers in this study were
predominantly White and all care recipients were cognitively impaired. We do not know if results of our evaluation
would apply to caregivers of other ethnic and social backgrounds. Moreover, it is unclear how well these results
would generalize to caregivers providing assistance to relatives with only physical impairments.
This evaluation represents an important step in understanding the effects of community-based long-term care services such as adult day care. Several notable questions remain unanswered. Given the benefits of adult day care, why
do some caregivers wait so long to use this help, and why
do some leave the program so soon? Additionally, why do
so many caregivers never use adult day care or other respite
service, even in places such as New Jersey, where these services are readily available? We also need to understand what
the benefits of adult day care are compared to other respite
services, and how different services might assist caregivers
at different points in the course of caregiving. Carefully designed evaluations can contribute to an understanding of the
caregiving process and identify the most promising strategies for relieving a portion of stress on family caregivers.
ACKNOWLEDGMENTS
This research was supported in part by grant 1 RO1 AG11354 from the
National Institute on Aging.
We acknowledge the support and encouragement received from Marcia
Ory at NIA and Enid Light at the National Institute of Mental Health. We
also acknowledge the many students who made valuable contributions to
this work, including Caryn Goodman and Victoria Steiner, who were involved in development of the original project, and Mary Beth Alspaugh,
Audie Atienza, Sarah Clark, Adam Davey, Anne Edwards, Steve Feinstein,
Elia Femia, Joseph Gaugler, Shannon Jarrott, Jessica Kirby, and Sara
Leitsch. Special thanks are extended to Elizabeth Ferraro, who directed
data collection in New Jersey; Karen Babri, who directed data collection
in Ohio; and Jennifer Druley, who assisted in preparing this article. We are
also grateful to the adult day care programs and their staffs, who took time
from their busy schedules to participate in the study, to the Alzheimer's
Association chapters who helped with recruitment in Ohio, to our skillful
and dedicated interviewers, and to the caregivers in the study who generously shared their experiences with us.
Address correspondence to Dr. Steven H. Zarit, Gerontology Center,
The Pennsylvania State University, Henderson South 105, University
Park, PA 16802. E-mail: [email protected]
Callahan, J. J., Jr. (1989). Play it again Sam—There is no impact. The
Gerontologist, 29, 5-6.
Cook, T. D., & Campbell, D. T. (1979). Quasi-experimentation: Design
and analysis issues for field studies. Chicago: Rand McNally.
Cox, C. (1997). Findings from a statewide program of respite care: A comparison of service users, stoppers, and nonusers. The Gerontologist, 37,
511-517.
Derogatis, L. R., & Spencer, P. M. (1982). The Brief Symptom Inventory
(BSI): Administration and procedures manual—7. Baltimore, MD:
Johns Hopkins University School of Medicine, Clinical Psychometric
Research Unit.
Gottlieb, B. H., & Johnson, J. (1995). Impact of day care programs on
family caregivers of persons with dementia. Guelph, Ontario: Gerontology Research Centre, University of Guelph.
Guttman, R. (1991). Adult day care for Alzheimer's patients: Impact on
family caregivers. New York: Garland.
Henry, M. E., & Capitman, J. A. (1995). Finding satisfaction in adult day
care: Analysis of a national demonstration of dementia care and respite
services. Journal of Applied Gerontology, 14, 302-320.
Knight, B. G., Lutzky, S. M., & Macofsky-Urban, F. (1993). A meta-analytic review of interventions for caregiver distress: Recommendations
for future research. The Gerontologist, 33, 240-248.
Kosloski K., & Montgomery, R. J. V. (1993). The effects of respite on
caregivers of Alzheimer's patients: One year evaluation of the Michigan model respite program. Journal of Applied Gerontology, 12, 4-17.
Lawton, M. P., Brody, E. M., & Saperstein, A. R. (1989). A controlled
study of respite services for caregivers of Alzheimer's patients. The
Gerontologist, 29, 8-16.
Lawton, M. P., Moss, M. S., Kleban, M. H., Glicksman, A., & Rovine, M.
(1991). A two-factor model of caregiving appraisal and psychological
well-being. Journal of Gerontology: Psychological Sciences, 46,
P181-P189.
Lundervold, D., & Lewin, M. (1987). Effects of in-home respite care on
caregivers of family members with Alzheimer's Disease. Journal of
Clinical Experimental Gerontology, 9, 201-214.
Montgomery, R. J. V., & Borgatta, E. F. (1989). The effects of alternative
support strategies on family caregiving. The Gerontologist, 29, 457-464.
Montgomery, R. J. V., & Kosloski, K. (1995). Respite revisited: Re-assessing the impact. In P. R. Katz, R. L. Kane, & M. D. Mezey (Eds.),
Quality care in geriatric settings (pp. 47-67). New York: Springer.
Pearlin, L. I., Mullan, J. T., Semple, S. J., & Skaff, M. M. (1990). Caregiving and the stress process: An overview of concepts and their measures. The Gerontologist, 30, 583-594.
Radloff, L. (1977). The CES-D Scale: A self-report depression scale for
research in the general population. Applied Psychological Measurement, 7,385^01.
Schulz, R., O'Brien, A. T, Bookwala, J., & Fleissner, K. (1995). Psychiatric and physical morbidity effects of Alzheimer's disease caregiving:
Prevalence, correlates, and causes. The Gerontologist, 35, 771-791.
Strain, L. A., Chappell, N. L., & Blandford, A. A. (1988). Changes in life
satisfaction among participants of adult day care and their informal
caregivers. Journal of Gerontological Social Work, 77(3/4), 115-129.
Vitaliano, P. P., Russo, J., Young, H. M., Teri, L., & Maiuro, R. D. (1991).
Predictors of burden in spouse caregivers of individuals with Alzheimer's disease. Psychology and Aging, 6, 392—402.
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS
scales. Journal of Personality and Social Psychology, 54,1063-1070.
Weissert, W. G., Elston, J. M., Bolda, E. J., Zelman, W. N., Mutran, E., &
Mangum, A. B. (1990). Adult day care: Findings from a national survey. Baltimore, MD: Johns Hopkins University Press.
Wright, L. K., Clipp, E. C , & George, L. K. (1993). Health consequences of
caregiver stress. Medicine, Exercise, Nutrition and Health, 2, 181-195.
Zarit, S. H. (1990). Interventions with frail elders and their families: Are
they effective and why? In M. A. P. Stephens, J. H. Crowther, S. E.
Hobfoll, & D. L. Tennenbaum (Eds.), Stress and coping in late life
families (pp. 241-266). Washington, DC: Hemisphere Publishers.
REFERENCES
Aneshensel, C. S., Pearlin, L. I., Mullan, J. T., Zarit, S. H., & Whitlatch, C.
J. (1995). Profiles in caregiving: The unexpected career. New York:
Academic Press.
S277
Received July 24, 1997
Accepted May 1, 1998